Domestic Homicide and Suicide Review Taskforce minutes: June 2024

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Attendees and apologies

Attendees

• Anna Donald, Chair, Criminal Justice Division, Scottish Government

• Emma Forbes, Victims and Witnesses Policy Team, COPFS

• Samantha Faulds, Police Scotland

• Katie Brown, COSLA

• Graham McGlashan, Scottish Law Commission

• Ann Hayne, NHS Lanarkshire

• Fiona Wardell, Healthcare Improvement Scotland

• Edward Doyle, Scottish Government/NHS Lothian

• Marsha Scott, Scottish Women’s Aid

• Kate Wallace, Victim Support Scotland

• Ann Fehilly, ASSIST

• Iris Quar, Abused Men in Scotland (AMIS)

• Jess Denniff, SafeLives

• Khatidja Chantler, Manchester Metropolitan University

• John Devaney, University of Edinburgh

• James Rowlands, University of Westminster

• Sarah Dangar, City University of London

• Claire Houghton, University of Edinburgh

• Tamsyn Wilson, Justice Analytical Services, Scottish Government

• Joanna MacDonald, Social Work Advisor, Scottish Government

• Nel Whiting, Equality Unit, Scottish Government

• David Thomson, Equality Unit, Scottish Government

• Jeff Gibbons, Criminal Justice Division, Scottish Government

• Vicky Carmichael, Criminal Justice Division, Scottish Government

• Laura-Isabella Muresanu, Criminal Justice Division, Scottish Government

• Jude Thomson, Criminal Justice Division, Scottish Government

Apologies

• Faith Curry, Scottish Fatalities Investigation Unit, COPFS

• Deborah Demick, National Homicide Unit, COPFS

• Emma Fletcher, NHS Tayside

• Giri Polubothu, Shakti Women’s Aid

• Fiona Drouet, EmilyTest

• Laura Mahon, Alcohol Focus Scotland

• John Mulholland, Law Society of Scotland

• Lorraine Gillies, Scottish Community Safety Network

• Karyn McCluskey, Community Justice Scotland

• Lynne Taylor, Directorate for Mental Health, Scottish Government

• Michael Crook, Drugs Policy, Scottish Government

Items and actions

Welcome, introductions and apologies

Anna Donald (AD) welcomed members to the sixth meeting of the Domestic Homicide and Suicide Review Taskforce.  

AD also welcomed Graham McGlashan from the Scottish Law Commission, who will be attending as an observer.

AD outlined to members that some of what would be discussed in terms of subject matter might be difficult and sensitive. Emphasising the importance of everyone’s wellbeing, she invited members to take time out and look after themselves as required.      

Members were asked to introduce themselves when first speaking during the course of the meeting. Apologies were noted. 

AD provided an update to Taskforce members on the development of National Standards for the model, and noted that further discussions have been had with Healthcare Improvement Scotland. In terms of next steps, a roundtable would take place in the Autumn to determine whether this is the right approach or whether an alternative would be more suitable. Fiona Wardell (FW) added that the Autumn roundtable would consider what the current landscape is, as well as the benefits and limitations of standards, starting from identifying and analysing the problem, envisaging the standards as a suite of tools or resources that could contribute to the solution.

Minutes and actions

The minutes of the fifth Taskforce meeting were circulated to members for comments and subsequently published on the Scottish Government website, as agreed during the fourth Taskforce meeting in November 2023.

Vicky Carmichael (VC) mentioned that three of the five actions noted on the action log have been completed or are in process of being completed as part of the agenda for this meeting. The remaining actions are related to the use of homicide data in the development and operation of the model (A19), and the data being sought as part of the collation for the European Observatory report (A21). An update on these actions will be given at a future Taskforce meeting.

Marsha Scott (MS) added that with regards to the data required for the European Observatory report, she received a communication enquiring whether Scotland could be part of the report. MS remarked that while it would be beneficial to be included, some agencies and the third sector do not readily have access to such data, and perhaps gaining access to this information would be the greatest outcome from this work.

AD suggested that the two actions concerning data could be linked together and reported on as a single action during a subsequent Taskforce meeting.

Action 1: Scottish Government officials to merge actions A19 and A21 and provide an update on their progress at a future Taskforce meeting.

Risks and issues log

AD invited Laura-Isabella Muresanu (LIM) to provide an overview of the risks and issues associated with the work to develop a Domestic Homicide and Suicide Review model for Scotland.

LIM summarised that the risks and issues log was last considered by the Taskforce at its meeting in November 2023. LIM outlined that there are eleven risks that continue to be monitored, six of which fall under the medium-low to medium risk score, and five of which fall under the medium-high to high risk score, with mitigating measures in place for all.

LIM reminded Taskforce members that the identification and management of risks and issues is a collective process, as such, members were welcome to propose any other risks that they considered relevant, or provide comments on those already discussed.

Kate Wallace (KW) commented that in relation to the risks associated with the availability of members of the Taskforce, Model Development Subgroup, and Task and Finish Groups to undertake this work, there is a focus on the time and delay that this lack of engagement would cause, however, there could be a significant impact on the quality of outcomes as well, particularly where there are agencies that are entirely absent from the process. KW further reflected on the scoring of the risk related to the divergence of views existent between members of the various groups, and suggested that rather than this being considered a potential negative, it could be reframed as an opportunity to have a robust conversation that would result in a comprehensive model being developed, avoiding the pitfalls of group-think.

JD mentioned that KW’s point about attendance and participation in Model Development Subgroup discussions is especially valid and important, particularly now, when the work is moving into a very detailed stage. JD added that while previous meetings have been well-attended, due to a variety of reasons, there has been a decrease in attendance during the most recent meetings of the group, and going forward these should be proactively considered to ensure that there are no obstacles to agencies’ participation. JD also acknowledged the welcome challenge of thinking critically, having constructive debates, and creating safe spaces where ideas can be deconstructed and reconstructed collaboratively to produce the best outcome possible.

MS acknowledged that this process  will improve the model and the subsequent outcomes. However, MS cautioned that it should not be readily accepted that development at a slower pace is necessarily part of the process of producing high-quality outcomes, and stressed the urgency of the work. MS suggested that this would constitute an additional risk, which could potentially be mitigated by moving into an immediate stage of testing the model even when if not all aspects of it have been clarified, given the potential that it would have to save lives.

AD shared MS’s concerns of not being able to provide an immediate solution, and acknowledged that every death that occurs is a tragedy that members wished to have seen prevented. AD reflected that introducing a review process as soon as possible would not immediately prevent such deaths, and members of this group are collectively working towards a long-term solution. AD proposed revising the primary risks associated with this work and giving further consideration to the testing of the model.   

Action 2: Scottish Government officials to update the risks and issues log in accordance with Taskforce members’ comments.

Model Development Subgroup update

AD invited John Devaney (JD) to provide an update on the work of the Model Development Subgroup and the Domestic Abuse Related Suicide Working Group which has been established to progress some initial work.

Model Development Subgroup update

JD mentioned that between March and June 2024, the Model Development Subgroup met three times and discussed the following:

• The notification process following a death and the review of the notification

• Appointment of the Review Oversight Committee, with recommendation for an independent Chair, and likely a Deputy Chair, who will review the notifications received, determine whether a case meets the criteria for a review, draft the terms of reference for a review, and appoint an Individual Case Review Panel.

• Appointment of Individual Case Review Panels and independent Chairs

• Development of the draft statutory guidance contents page

• The process and options for undertaking individual case reviews

JD highlighted that the next steps in the work of the Model Development Subgroup will be determining the various stages of the model itself, which will then inform the tools and resources necessary to make the model operational. JD added that in the first instance, four Task and Finish Groups will be required, two of which have already had their first meeting – a subgroup of the Domestic Abuse Related Suicide Task and Finish Group, and the Children and Young People Task and Finish Group. The Information Governance Delivery Group has been set up and is yet to meet for the first time, whereas the Workforce and Training Task and Finish Group is in process of being set up.

JD mentioned that the Model Development Subgroup would appreciate input from Taskforce members on the options for gathering information to use as part of individual case reviews. The options included: ‘Case Record Review’, ‘Individual Agency Review’, and ‘Facilitated Learning Events’.

Case Record Review

In a ‘Case Record Review’, all involved agencies provide a copy to the Individual Case Review Panel of their records on the victim, the accused/ convicted, and children etc. The panel then reviews these records and may supplement them with interviews or discussions with family members and/ or practitioners involved in the case. The primary advantage of the ‘Case Record Review’ is the access to the real time information on the case. The disadvantages include potential difficulties in accessing certain type of records, such as GP records due to data protection considerations, the partiality of recorded information, the associated workload for panel members, and the possibility that records may not contain all the relevant information required by the panel or that the records are recorded in such a way that to a person out with that organisation, the information may be difficult to interpret.

Individual Agency Review

In an ‘Individual Agency Review’, all involved agencies produce a chronology and a report for the Panel detailing their involvement with the victim, the accused/ convicted, and children etc., and provide a reflective account of any learning the agency has gained following the death. The perspective of practitioners involved in the case is usually incorporated into the individual agency review. The panel then reviews the individual agency reviews and may supplement them with interviews or discussions with family members and/ or practitioners involved in the case. The advantages of this approach is the opportunity to support agencies to develop their own learning, and therefore ownership, and the potential for practitioners to feel less anxious contributing to the individual agency review. This option is also likely to create less work for Individual Case Review Panel than sifting through agency records. The disadvantages are a potentially extended timeline for completing the review, as this depends on the completion of agency reviews in first instance, as well as the risk that practitioners may be interviewed twice. A further disadvantage is that by panel members not having sight of the persons records, relevant information within agency records may not be provided and consequently, opportunities for learning may be lost.

Facilitated Learning Event

In a ‘Facilitated Learning Event’, practitioners involved with the victim, the accused/ convicted, and children etc., meet with the Chair of the Individual Case Review Panel and members for a discussion about the case to gain a holistic understanding of the situation through a process of appreciative inquiry. This may be supplemented with interviews or discussions with family members. The primary advantages lie in the fact that a learning event can happen relatively quickly, and in discussing the case together, practitioners can gain new insights, which may meant that the process of learning can be started much earlier, while also providing practitioners with a sense of ownership in decision-making. The disadvantages include the high level of dependency on practitioner involvement and engagement, and managing potential tensions between practitioners, managers, and different agencies.

JD emphasised that across all three options, an effective secretariat that could support the work of both the Review Oversight Committee and the Individual Case Review Panels would be critical to the success of the model. JD also reminded Taskforce members that there is no single model that is perfect or representative of a gold standard, and the advantages and disadvantages of all these options would need to be carefully balanced. JD added that during the discussions of the Model Development Subgroup, members leaned towards an ‘Individual Agency Review’ supplemented by a ‘Facilitated Learning Event’. This would enable agencies to reflect on their involvement in the case but also allow the possibility of bringing practitioners together rather than interviewing practitioners individually, avoiding the associated impact on resources. JD noted that at this stage it would be recommended to start by implementing an option, evaluating its appropriateness as reviews are being undertaken, and amending it as necessary afterwards.  

VC reflected on Alcohol Death Reviews and Drug Death Review. One of them implemented a ‘Case Record Review’ approach, and apart from the length of time it took to analyse all the records shared, the impact of vicarious trauma on those who were undertaking or supporting the review process was not fully considered from the outset. In the second review, which adopted an approach similar to the ‘Individual Agency Review’, the information on the standard form submitted by agencies overlooked aspects that were later considered to be highly relevant. VC further noted that it is important to carefully craft the questions asked during reviews, as failure to do so could further lead to substantial omissions.

JD added that during the most recent meeting of the Children and Young People Task and Finish Group, it was raised that Child Protection Learning Reviews are carried out at local authority level, and members queried why the responsibility for undertaking a Domestic Homicide and Suicide Review would not also sit with local authorities, rather than being centralised. JD reflected on these issues, including the lack of expertise available in certain geographical areas and the multitude of review processes existing in Scotland at present, where the addition of another process may generate further confusion and inconsistencies in how this is undertaken.

Ann Hayne (AH) mentioned that she was involved in both case record reviews and individual agency reviews, and in the latter, agencies would set a time limit according to which they would look for relevant information, such as the last six months to two years of engagement with a victim. However, given the nature of domestic abuse and the fact that this can span multiple decades, such a time-limited approach could overlook valuable information from a person’s life. Ann observed that case records, despite the gaps that these may also present, would be a crucial part of looking at any domestic abuse case. Ann further mentioned that the ‘Facilitated Learning Event’ would be limited due to the longevity of cases, with a very low likelihood of having practitioners present who would have worked for the full duration of that experience. Ann noted her preference for a ‘Case Record Review’ to be implemented.

JD acknowledged AH’s arguments, specifically in relation to the high staff turnover that may exist in some agencies and the limitations that this may impose on undertaking a ‘Facilitated Learning Event’. JD added that the terms of reference may be adapted by the Review Oversight Committee for each individual review to address some other concerns, such as how far back in time an agency may look for information in a particular case.

JR mentioned that the strongest reviews in England and Wales are those which tailor their terms of reference to the case, including deciding on the timeframe required and having the option to go back as far as is needed, and managing that in the most appropriate way.

AH reflected on the vicarious trauma associated with this work and noted that a balance would have to be achieved between having experienced and competent practitioners who undertake this work with suitable supervision and support, rather than removing practitioners from the work to reintroduce them at a later point, which as a consequence may mean that a review is not undertaken for a few years.

Joanna MacDonald (JMcD) observed that often from reading the job description for the Chairs of such reviews there may be an expectation that the Chair does not require such support, however, this support is critically important. In relation to local authorities undertaking Domestic Homicide and Suicide Reviews, JMcD commented that in Scotland there is a gap in the learning that is shared nationally, especially where this has been produced locally, regardless of its quality. JMcD reflected that the national approach hopefully will support the whole of Scotland to improve in each of the localities.

KW agreed with AH’s point regarding case records as an essential component of the review process. KW noted that from family members’ perspective, there may be concerns about organisational reviews not being sufficiently independent, particularly evident in some reviews where the finding is that the death was not preventable, however, numerous recommendations are made about what could be done differently.

JD reinforced the importance of having independent Chairs for both the Review Oversight Committee and the Individual Case Review Panels, noting that this is not solely for managing the quality of the work, but also for ensuring that someone continues to speak for the deceased and centres the process on what can be learned from the death. JD recalled his experience as a panel member in a Confidential Enquiry Into Maternal Deaths, undertaken using a ‘Case Record Review’ approach, reflecting on the volume and impermeability of some records – such as healthcare records – and the need for having appropriate training to understand them. This may mean that there is a reduced pool of confident and competent practitioners with the necessary skillset.

AH commented that regarding health records, general medical terminology can be impenetrable for someone not previously exposed to them. Therefore, the presence of a healthcare professional on the review panel should be carefully considered.

MS enquired whether there is any indication that any one of the three options would be more appropriate for a particular situation, and highlighted that this may be an area where different approaches could be tested to generate learning on what each can produce. MS echoed the concerns about the independence of the reviews, while recognising that setting up processes that are time consuming could result in learning that becomes irrelevant by the time the review is completed.

JR reflected on the ‘Case Record Review’ option and agreed with JD’s points about the opportunity cost and the intelligibility of records, which is particularly significant for more complex cases. JR reflected from his experience of chairing reviews that having agencies undertake their own review is very valuable, partly because this centres them in a learning process in terms of generating their own recommendations. JD added that it is rare for agencies not to subject themselves to comprehensive scrutiny, although the difficulty may rest in how that is framed, which is where the corroboration of other reports and the expertise of the panel comes into effect as part of collective action.

VC drew attention to the fact that from a police perspective, there would be issues associated with the provision of case files and the data protection implications. VC noted that although likely not to be insurmountable, there may be a necessary of vetting people to enable information sharing, and when thinking of testing the three options, information governance becomes particularly important.

AD asked about the impact that these model options may potentially have on families and the learning for practitioners, as each option may drive the efforts in a different direction and require a varied amount of time for completion. AD emphasised the need to be realistic about the practicalities of the system that is implemented and the results that are being delivered. AD also queried the legal basis for the different model options, and whether there would be additional considerations that would need to be built in when thinking about making legislative provisions.

JD returned to MS’s comment about the possibility of implementing all three model options and then using the one that emerges as the most appropriate, and reflected that this approach is used in England and Wales. JD noted that there may be practical difficulties associated with this approach. Regarding the involvement of family members and their experience of the review process, JD recognised that this would need to be carefully considered, and equally important would be ensuring the confidence of family members that the review is sufficiently independent even when the outcome is not what they would have anticipated or wanted. JD noted that there are distinct issues in relation to the legal basis for each of the three model options, but essentially these are connected to the sharing of information on a multi-agency basis outside of existing frameworks and information sharing agreements.

Jessica Denniff (JeD) observed that it may be necessary to collectively agree the final output of each review, whether that would be a series of recommendations, a local action plan, or something different. JeD reflected that she would welcome a ‘Facilitated Learning Event’ focused on which agencies should be involved in the discussions with the potential of providing something additionally beneficial.

AH mentioned that a model using multiple review options could potentially make it difficult to follow thematically across cases if they were reviewed differently. Sarah Dangar (SD) agreed with AH and added that multiple models could be problematic for families and could raise questions about why their loved one is considered under a particular model as opposed to another, which may create a sense of hierarchy of models or a perceived hierarchy.

Domestic Abuse Related Suicide Working Group update

JD noted that the full group has not met yet due to the illness of the Chair, however, a  smaller working group met to discuss certain aspects of the work that would need to be clarified as soon as possible, such as the definition of ‘domestic abuse related suicide’ and how such cases would be identified for review.

Children and Young People Task and Finish Group update

AD invited Edward Doyle (ED), Chair of the Children and Young People Task and Finish Group, and Claire Houghton (CH), Deputy Chair, to provide an update on the work of the group.

ED noted that the first meeting of the group was very well-attended and there was a collective sense of purpose in the work being undertaken. ED observed that some of the issues that emerged from the discussions of the group concerned the definition of a ‘child’, with group members agreeing to maintain the position of up to 18 years old and 26 years old for care experienced young people, consistent with the definition used with Child Protection guidance. ED mentioned that the group considered it necessary to better understand the complex reviews landscape that exists in Scotland and avoid duplication of work, particularly when accounting for a lack of human and financial resources. The group is currently looking into the best approach to adopt when involving children with experience of domestic abuse and domestic homicide, and this may be an extended process. ED further added that the group intend to implement the principles of the UN Convention on Rights of a Child (UNCRC) and make the reviews rights-based.

CH added that the group will also look at the lack of data concerning children and young people and domestic abuse, and the learning that has been generated in this regard in other jurisdictions.

AH commented that during MARACs in Lanarkshire, there has been an increased prevalence of young people who are in high-risk, domestically abusive relationships themselves, rather than being collateral victims of their parents’ abusive relationship.

SD reflected that there is a dearth of data and research internationally around children taking their own lives in the context of domestic abuse or due to the impact of domestic abuse.

JD mentioned that in the past few years there have been no deaths of children and young people due to domestic abuse within the context of partners/ ex-partners, although this does not mean that it won’t happen in the future. JD added that in terms of the model, there is no age limit associated with it, although should the death of a child occur in such circumstances, the review should be considered alongside other processes, such as Child Protection Learning Reviews, and a suitable protocol established. AH highlighted that in these cases, the learning would be around the dynamics of domestic abuse, albeit in a young relationship.

MS recalled the discussions that took place in relation to the Children (Care and Justice) (Scotland) Bill around the young female victims within the children’s hearing system, whose perpetrators are also in the hearing system, and questioned whether the information available in that system is shared more widely. MS indicated that the incidence of unreported domestic abuse among children and young people could be significantly higher than that of adults, and this aspect should be further explored.

AD added that although there have not been recent domestic homicides that resulted in the death of a child of young person, there may have been domestic abuse related suicides, the data for which is unavailable. KW reinforced AD and MS’s remarks, noting that domestic abuse tends to be minimised in adolescent relationships.

CH noted that an important point applicable across all groups in relation to a death is the relevance of knowledge/ data/ records etc., regarding the child/ren (mother/siblings), given the relational nature and shared 'story' of domestic abuse. CH observed that the discussion has mainly focused on agency involvement with the victim/perpetrator.

AD thanked Taskforce members for their valuable contributions and drew the discussion to a close.

Perpetrator involvement in Domestic Homicide and Suicide Reviews

AD invited JR to present on perpetrator involvement in Domestic Homicide Reviews in England and Wales.

JR summarised that the data for this research was collected as part of his doctoral thesis completed at the University of Sussex, which investigated how Domestic Homicide Reviews – now named Domestic Abuse Related Death Reviews – in England and Wales operate and produce knowledge. JR noted that in England and Wales, there is still substantial stigma associated with the involvement of perpetrators in the review process, and such involvement can happen either directly or by proxy, usually commencing after the conclusion of the criminal justice process. JR observed that there is limited guidance available on perpetrator involvement and mentioned that some of the issues arising are related to:

• difficulty in gaining access to the perpetrator, e.g., due to the timeframe of reviews;

• questions around the structuring of involvement, e.g., perpetrator experience and needs, the focus of the interviews, and ethics;

• issues around veracity and intent, e.g., minimisation, denial and blame; and

• issues with family involvement

JR reflected that some of the lessons emergent from this research highlight the need to:

• identify potential issues from the start and then review following the conclusion of the criminal trial;

• agree on an approach with the Individual Case Review Panel, including how to access, e.g., via prison through the governor/offender manager;

• set clear boundaries to involvement in terms of process and nature; underpin the involvement by an understanding of purpose, e.g., victim-focused;

• Ethical practice, including capacity, capability, support needs, and rights as an interviewee; and

• the consideration of family involvement on a case-by case basis

JR concluded that the involvement of perpetrators in the review process raises practice and policy questions and tensions, as well as ethical concerns, which are relevant to the victim and their surviving family, but also the perpetrator and their family.

AD recalled that the targeted engagement undertaken last year showed a lack of support for including perpetrators, family, children, friends and work colleagues of the perpetrator in the review.

SD noted that from her experience of working with families of perpetrators, she recognises JR’s point about the lack of support available and the trauma that these families often experience as a result of the perpetrator’s actions, such as losing access to grandchildren, losing a loved family member – their daughter-in-law or son-in-law – perhaps in circumstances where the domestic abuse was not readily visible, and their involvement in the review process could potentially be healing for them. SD further suggested that it would be helpful to understand perpetrators' perspectives and interactions with services, which could potentially inform behaviour change work.

VC reminded Taskforce members of the point that Khatidja Chantler (KC) had made in the past, indicating that perpetrators can be involved in the reviews without being given a voice.

JD mentioned that it would be helpful to understand the perpetrator’s perspective without accepting this as a valid and accurate perspective. JD observed that perpetrators can continue to exert coercive control over the family – particularly children – even when convicted and in prison, and without careful consideration, this could extend to the review process. AD recognised this tension and the ethical issues associated with such involvement, but also the rich learning that could emerge from this.

KW suggested that it would be useful to consider the timeliness of such endeavours, as well as the support available for the perpetrator’s family, particularly when considering that some cases may present an added layer of complexity, such as cases of murder-suicide.

Neil Whiting (NW) reflected that going forward it may be useful to have some of the experts working on the Caledonian Programme involved in some of the thinking around this issue.

AH queried whether there would be a possibility that the victim's family could veto the involvement of a perpetrator. JR answered that this would depend on circumstances, and it would be necessary to understand the family’s concerns, which might be a reason not to engage the perpetrator, e.g., safety risk, or it may be more about reassurance, such as explaining how this is done and the safeguards that are in place. Tamsyn Wilson (TW) observed that this would be particularly important in cases of 'honour' based violence, where family members may have been involved or complicit in abuse.

Statutory Guidance

JD invited Taskforce members to provide comments on the draft contents page that the Model Development Subgroup developed for the statutory guidance.

ED queried whether there should be a template available for the Individual Case Review Panel to raise any concerns that came to light and which may have been unknown before, such as immediate risks, or the realisation that situation is more complex than previously thought, as this would require a formal process of escalation. JD answered that this would be an excellent suggestion.

AD reflected on a point previously made on the way in which the outcomes of the review are presented, and how these outcomes would then inform the choice of model option. AD suggested that adopting this reverse engineering approach for the report template as well may prove beneficial.

Action 3: Taskforce members to share with Scottish Government officials their comments on the draft statutory guidance.

Action 4: Scottish Government officials to include a template for a formal process of escalation in the statutory guidance.

Action 5: Scottish Government officials to circulate to Taskforce members the membership of the Model Development Subgroup and Task and Finish Groups.

Any Other Business (AOB)

N/A

Date of Next Meeting (DONM)

The next meeting will take place on Thursday, 5 September 2024, 14:00 – 16:00.